HIP JOINT EXAMINATION orthopaedis ppt.pptx

Orthopedic presentation

1. HIP JOINT EXAMINATION & HIP RADIOLOGY SUSAN KURIEN 2020 BATCH

2. LOCAL EXAMINATION inspection GAIT- bipedal aided or unaided stable or unstable coordinated or not antalgic ATTITUDE- It is the position of ease- the patient is examined in the supine position look for exaggerated lumbar lordosis asis (same or different level) comment on the position of the limb starting from hip, knee, ankle, foot

3. Trendelenberg test Normally when the weight of the body is taken on one leg the pelvis rises on the other side. This is due to the pull exerted by the abductors of the hip. The patient is asked to stand on the unaffected limb first, the buttock on the affected side automatically rises. The patient is the asked to stand on affected limb- the pelvis on the opposite side sinks- trendelenberg positive SOUND SIDE SINKS (SSS) Trendelenberg’s positive sign is commonly seen 1.when abductors are weak- poliomyelitis, muscle dystrophies, motor neuron disease 2. Congenital or pathological hip dislocation 3.Fracture of neck of femur, perthes ’, coxa vera etc;

4. FIXED FLEXION DEFORMITY THOMAS’ TEST (in unilateral cases) In recumbent position the normal thigh is bent with flexion of knee upto the point to obliterate the lumbar lordosis. This will flex the affected thigh to the extend of fixed flexion deformity. The angle between the affected thigh and the horizontal line is the angle of fixed flexion deformity.

5. Adduction deformity Square the pelvis first‐means if ASIS is at higher level, implies, adduction deformity. So further adduct the affected limb so that the ASIS of the affected limb is brought to the same level as the normal hips ASIS. Draw a vertical line from ASIS of affected hip downward , and angle subtended between the imaginary vertical line and the line along the long axis of the thigh is the adduction deformity . In adduction deformity there will be 1. Apparent shortening 2. (TS<AS)(True shortening less than apparent shortening ) 3. Scoliosis—convexity to the opposite side

6. Abduction deformity Square the pelvis first, ‐means if ASIS is at Lower level, implies abduction deformity. So further abduct the affected limb so that the ASIS of the affected limb is brought to the same level as the normal hips ASIS. Draw a vertical line from ASIS of affected hip downward , and angle subtended between the imaginary vertical line and the line along the long axis of the thigh is the abduction deformity. In Abduction deformity there will be 1.Apparent Lengthening 2. TS>AS (true shortening more than apparent shortening ), 3. Scoliosis—Convexity to the same side.

7. FIXED LATERAL OR MEDIAL ROTATION DEFORMITY Determined by noting the direction of anterior surface of the patella or of the toes the foot is held at right angle to the leg. Normally the lower limb remains in a slight lateral rotation. In recumbent position if the patella or toes point upto the ceiling it indicates slight medial rotation.

8. Tuberculous arthritis of the hip joint

9. Adolescent coxa vara - marked external rotation with slight adduction due to eversion of the femur resulting from upper epiphyseal separation Congenital dislocation of hip Attitude that of lordosis- b/l cases with undue protrusion of the abdomen and buttock posteriorly u/l cases- grooves between labia and the thigh are asymmetrical and an additional skin crease on medial side of thigh 2. Muscular wasting 3. Swellings

10. PALPATION Superficial palpation‐ local raise in temperature(septic hip) and increased superficial tenderness(seen in cellulitis) Deep palpation – Tenderness‐in scarpa triangle , Anterior hip joint line, over the trochanter, posterior hip joint line ( obers point)

11. Palpation and Bony Examination 1 Trochanter Palpation Palpate the level of the trochanter, looking for tenderness, irregularity, thickening, or broadening, which may indicate a malunited trochanteric fracture or fibrous dysplasia. 2 Palpation of hip joint Hip joint lies in its socket and is almost inaccessible, only a small part of neck may be palpated. A finger is placed just below the inguinal ligament and lateral to femoral artery,the finger is pressed deep to detect tenderness. 3 Assess the vascular sign of Narath by feeling for femoral pulse, which not felt indicates a positive sign seen in cdh 4 Swelling Effusion of hip joint- suppurative arthritis- jst below the midinguinal point. Cold abcess can be palpated . Vascular sign of NARTH

12. Movements                     FL‐120, EX 15, ADD 30, ABD 40, IR 30, ER 45 Check whether this rom is  associated with pain(SYNOVITIS, OA,TB,),  spasm(TB),  crepitus (OA), mechanical block(foreign body)

13. Examination of stability Mainly lost in congenital dislocation of hip. The tests done include Telescopic test- the pelvis is fixed with one hand touching the greater trochanter. Hip flexed to 90 and knee is grasped with one hand of the clinician who pushes the thigh downwards along the axis of the thigh with this hand while other hand notes whether the greater trochanter is moving downwards Positive seen in congenital and pathological dislocation of hip joint and charcot’s joint

14. ORTOLANIS’S TEST Both hips and knees are flexed by holding the limbs. Thigh of the affected side is gradually abducted. A click of entrance is felt as the femoral head slips into the acetabulam and a click of exit as it quits the acetabulam when the pressure is released.

15. BARLOW’S TEST The surgeon holds both the lower extremities in such a way that the hips are flexed at 90° and the knees are fully flexed. The lower limbs are now complete and pressure is exerted downwards along the bony axis of the femur while the little fingers of both the hands are placed on the greater trochanters. If the hip is dislocatable , the femoral head will be heard to roll over the posterior rim of the acetabulum as a distinct 'cluck! The hip is dislocated. The second phase of the test is started. The hip is now gradually abducted from the position of full adduction. The little fingers on the greater trochanter are now pushed inwards simultaneously. The head can now be felt to reduce with a soft cluck into the acetabulum.

16. measurements

17. Girth of the limb- measures to find out wasting A mark is made on the affected limb at a convenient distance from asis . This mark is made on both limbs and circumference of the limbs is compared. Shortening above the greater trochanter. 1. Bryant’s triangle -line drawn vertically down from asis and another from tip of the same spine to tip of greater trochanter and a horizontal line from the tip of the trochanter to the first line. Deminution in the length of the horizontal line is compared with the other side. 2. Nelaton’s line

18. Lymph nodes- important in inflammatory conditions Other joints- other major joints like lumbosacral spine, sacroiliac joints and knee joint should be examined Rectal examination- if intrapelvic abcess is suspected in tuberculous arthritis.

19. radiology

20. CONGENITAL HIP DISLOCATION

21. LESSER TROCHANTER AVULSION FRACTURE FRACTURE OF NECK OF FEMUR INTERTROCHANTERIC FRACTURE

22. POSTERIOR HIP DISLOCATION

23. SLIPPED CAPITAL FEMORAL EPIPHYSIS

24. PERTHES DISEASE TUBERCULOUS SEPTIC ARTHRITIS

25. REFERENCES S DAS- A MANUAL OF CLINICAL SURGERY APLEY AND SOLOMON’S –SYSTEM OF ORTHOPEDICS AND TRAUMA

26. Thank you